0:12Skip to 0 minutes and 12 secondsBAYARD ROBERTS: Mortality is probably the most important indicator of health needs in a humanitarian crisis and also the effectiveness of the humanitarian health response. There are a number of challenges with current methods for estimating mortality, which tend to be retrospective mortality surveys or prospective surveillance systems. We looked at trying to develop a new method for mortality estimation, which involved asking members of the community as key informants about deaths that had occurred within their community and then also a snowballing approach of visiting households where death had occurred and asking if they were aware of where other deaths had occurred within that community.

0:56Skip to 0 minutes and 56 secondsAnd then we tried to validate our results for mortality estimation against the gold standard using a statistical method called capture recapture. And so we did this in four very diverse settings of a messy urban environment in Kabul, refugee camps on the Thai-Burma border, and also in Western Tanzania, and also a very poor, rural setting in Malawi. What we found was that our method didn't work as well as we hoped. But actually, it was no worse than the surveillance systems that were operating in the refugee camps, which were often seen as the sort of best method available. So what this really highlighted is the existing methods for mortality estimation are essentially missing a lot of deaths.

1:55Skip to 1 minute and 55 secondsJIMMY WHITWORTH: One of the striking things about outbreaks of infectious diseases is the disproportionate amount of chaos and disruption that they cause relative to their public health impact. So for example, the recent Ebola outbreak brought three West African countries to their knees for a period of 18 months, two years, yet there were only 28,000 cases in total during that time. And that pales in significance if you compare that with, say, maternal deaths or childhood diarrhoea or so on. But the amount of disruption caused in social and economic terms was enormous. If I take another example, which was the SARS outbreak in 2002, there was something like 8,000 cases in total in the world.

2:57Skip to 2 minutes and 57 secondsBAYARD ROBERTS: So the prevalence of NCDs has increased during the last decade or so, including in emergency settings. And this principally relates to global changes and epidemiological and demographic profile in low- and middle-income countries. So we've seen the rise of NCDs as communicable diseases have declined, particularly childhood diseases. So people are living longer. Life expectancy is increasing. And as a result of that, people are experiencing NCDs at greater rates. In addition, we're seeing changes in lifestyles and diets, which are major causes of NCDs. So for example, more sedentary lifestyles, less active work patterns, greater consumption of high-sugar or high-fat food and drinks. And so this is all combined to increase prevalence and incidence of NCDs.

3:49Skip to 3 minutes and 49 secondsAnd inevitably, this is impacted on populations affected by humanitarian crises, particularly as an increasing number of those crises are taking place in middle-income countries, where there is already an extremely high burden of NCDs. The main mental health needs in emergencies commonly relate to Post-Traumatic Stress Disorder or PTSD, depression, anxiety, somatic distress, and also substance misuse, such as alcohol misuse. There are also a range of locally defined and conceptualised mental health needs that need to be recognised when responding to the mental health needs of crisis-affected populations. The main causes of poor mental health amongst crisis-affected populations principally relate to exposure to violent and traumatic events, including being forcibly displaced from homes, such as being a refugee or an internally displaced person.

4:53Skip to 4 minutes and 53 secondsBut they also relate to a whole range of daily stresses. So that might be impoverishment, loss of jobs, loss of livelihoods, isolation, social exclusion, and so on. And so all of these factors combine to lead to elevated levels of poor mental health.

5:13Skip to 5 minutes and 13 secondsSARA NAM: So when we talk about sexual and reproductive health, we're talking about access to family planning and to emergency contraception, to safe abortion care where that's legal and to post-abortion care, to care of women during pregnancy, labour, and the post-natal period, care for their babies, neonatal care, and to care for STIs and prevention of STIs and HIV. We know that mothers, adolescents, and babies living in humanitarian settings and crises are more vulnerable and at risk of death and of disability related to their inability to access care. The 2016 Lancet maternal series, for example, showed that the highest burden of maternal mortality was clustered among those countries which are fragile states.

6:13Skip to 6 minutes and 13 secondsOver half of all maternal and newborn deaths occur in around 50 countries which are categorised as fragile states, which are also more susceptible to armed conflicts or natural disasters.

6:28Skip to 6 minutes and 28 secondsSPEAKER: This slide shows how crises can impact on populations, households, and individuals. So we see how a trigger such as a war or national disaster can impact on populations. For example, it can destroy infrastructure, roads, markets. It can lead to migration. It can lead to breakdown of essential health services, such as water sanitation. And these things all impact on households, which might not be able to access food in the same way as they used to. Things can be overcrowded. There could be lack of water, hygiene, sanitation. And these things all ultimately impact on individuals and could result in malnutrition, disease, and ultimately death. On the left side of this slide, I highlight breastfeeding.

7:09Skip to 7 minutes and 9 secondsSo this has a key role in maintaining nutrition and the health of vulnerable infants in any setting but especially in emergency settings, where it can be difficult, if not impossible, to get good supplies and clean water to make replacement milks. And this is one great example of something that's simple, cheap, yet highly effective. And I want to highlight that supporting breastfeeding is a key intervention in many emergencies to maintain good child and infant health. So if a community or society has limited background resilience, and if the crisis is severe enough, one of the first manifestations and warnings of a problem is child malnutrition. If not dealt with quickly, this can increase the risk of disease and ultimately death.

7:48Skip to 7 minutes and 48 secondsAnd there are different types of malnutrition. And the one we focus on most is acute malnutrition, since this is particularly associated with high risk of mortality. And this happens when weight loss is rapid. And it's assessed by low weight-for-height and/or low mid-upper arm circumference. But it's also important to note other types of malnutrition, and especially important to say that many types of malnutrition can co-exist in the same child. And the more different types you have, the more vulnerable that child is. So among these other types, there's underweight, which is also known as acute and chronic malnutrition. And this is defined by a low weight-for-age.

8:26Skip to 8 minutes and 26 secondsThen there stunting, which is also often known as chronic malnutrition and is defined by low height-for-age. And finally, there are many different kinds of micronutrient malnutrition. For example, vitamin A deficiency, iron deficiency, and some kinds of malnutrition have general increased effects on risk of death, risk of disease.

Crises and health outcomes

We have seen that the context of a crisis can vary, but regardless of the type how do they affect our health?

In this step we provide an overview of the effect of humanitarian crises on health outcomes. We begin discussing the importance of measuring mortality in emergency settings and the tools used to do this, before different experts discuss sector-specific outcomes including those relating to infectious diseases, non-communicable diseases, nutrition, mental health, and sexual and reproductive health.

A broad cross section of outcomes is covered here, but what other health effects can you think of?